It’s Not Burnout. It’s Moral Distress.

Clinicians aren’t burning out from overwork. They’re burning out from moral sacrifice — wrapped in metrics and sold as care.

Ask anyone about healthcare reform, and you’ll get passionate responses.

Single-payer or market-driven?

Universal coverage or cost-containment?

Clinicians, though, usually want something simpler:

→ Less charting. More caring.

But there’s a quieter, deeper conversation that’s rarely included when we talk about healthcare’s problems: Moral distress.

Not just the vivid, unforgettable distress we witnessed during COVID —
but something quieter, more chronic, and more insidious. It’s the kind of distress that comes from working in systems that subtly but relentlessly require clinicians to sacrifice their ethical integrity.

What We Miss When We Talk About Burnout

Moral distress is what happens when you know the right thing to do — and the system prevents you from doing it.

It happens when hospital policy, insurer mandates, and institutional hierarchies force clinicians to choose compliance over conscience — not once, but repeatedly, until it becomes part of the job description.

Unlike burnout, moral distress isn’t primarily exhaustion. Unlike trauma, it isn’t primarily fear. Instead, moral distress arises from an unspoken, collective agreement to pretend things are fine when they’re clearly not. It’s the quiet erosion of professional identity — the gradual realization that what you’re doing daily doesn’t align with why you chose this profession in the first place.

The Psychological Toll of Ethical Compromise

As a psychologist and healthcare ethicist, I spend my days with physicians, nurses, and therapists. They didn’t go into medicine to click boxes. They came to alleviate suffering.

I hear the same stories again and again:

• Watching executive compensation increase dramatically, while being told there’s no room in the budget to safely staff a night shift.
• Implementing care plans dictated not by clinical judgment or patient need — but by insurers and pharmacy benefit managers.
• Sitting through productivity meetings celebrating “solutions,” while quietly watching those solutions fail patients at the bedside.

Systemic Gaslighting in Healthcare

Perhaps the most disorienting part is that clinicians attend meetings in which administrators confidently explain how these “innovative solutions” and “streamlined workflows” are improving patient care, even as frontline staff witness outcomes deteriorate. It’s the healthcare equivalent of “the emperor has no clothes” — a subtle but profound institutional gaslighting that compounds moral distress, causing clinicians to quietly question their perceptions, judgment, and even sanity.

Over time, clinicians aren’t merely tired — they carry what ethicists call “moral residue.” This residue doesn’t fade after vacation or mindfulness exercises; it accumulates into a lasting emotional injury, fundamentally reshaping a clinician’s relationship to medicine and their own sense of moral integrity.

Why the DSM-5 Fails Clinicians

During Mental Health Awareness Month this May, you’ll hear plenty about burnout and resilience. But moral distress-the subtle, persistent ethical injury behind so much clinician suffering-will likely remain unnamed.

Moral distress doesn’t affect everyone equally. Those with less institutional power-clinicians in junior roles, or who identify as marginalized in any number of ways-bear a heavier burden. Moral distress compounds pre-existing inequities and exacerbates isolation and helplessness. It’s often these same clinicians who feel least empowered to speak up.

The DSM-5 and ICD-10 do an adequate job of naming anxiety, depression, burnout (Z73.0), and trauma symptoms.

But they miss the ethical root of these conditions entirely.

By medicalizing the symptom — burnout — we avoid diagnosing the deeper fracture: the moral injury beneath it.

What Needs to Change — And Why Resilience Isn’t Enough

Moral distress isn’t a hospital policy issue.

We have intentionally built healthcare as an economic system designed primarily around revenue optimization, payer-driven mandates, and efficiency metrics. In such a system, ethics aren’t completely disregarded — they’re just consistently deprioritized.

The system subtly communicates to clinicians that ethical integrity is a luxury — something admirable, but ultimately optional.

We don’t need more resilience training. Clinicians aren’t breaking because they lack resilience. They’re breaking because the price of continued employment is ongoing ethical compromise.

Instead of asking clinicians, “How can we make you more resilient?” perhaps we should ask the harder, more meaningful question…

What fundamental changes must we demand of healthcare so clinicians no longer have to compromise their integrity — just to stay employed?

Only when we clearly name moral distress — and address it directly, as the profound ethical crisis it truly represents — will we begin to heal health care, for clinicians and patients alike.

Dr. Jenny Shields is a licensed clinical psychologist and nationally certified healthcare ethics consultant specializing in clinician burnout, moral distress, and ethical injury. She is the founder of Shields Psychology & Consulting, PLLC, a private practice serving physicians, nurses, therapists, and healthcare leaders across the U.S. Through her writing, speaking, and consulting, Dr. Shields advocates for shifting the conversation from resilience to structural change. Learn more at drjennyshields.com.

Originally published at https://kevinmd.com on May 3, 2025.